Conditional cash incentives, community health workers, and continuum of maternal and child healthcare: evidence from India.

BackgroundThe continuity and quality of maternal and child health (MCH) services represent significant challenges in low- and middle-income countries (LMICs). Home-based records (HBRs), including the integrated Maternal and Child Health Handbook (MCHHB), may support consistent service usage and improved care quality. We aimed to evaluate the association between HBRs and continued quality MCH care, identifying differences in associations between MCHHBs and the continuum of care and those between other HBR types and the continuum of care.MethodsWe conducted a pooled analysis of Demographic and Health Surveys (DHS) from 18 LMICs, including women and their youngest eligible children for the health card module. We defined the continuum of quality MCH care using receipt of quality antenatal care (ANC), skilled birth attendance, and quality postnatal care (qPNC), with ANC and PNC measured as composite indicators. We based the HBR ownership on the DHS variable ‘Has health card’. We used multivariable logistic regressions to examine associations between HBR ownership, HBR type, and the continuum of care, adjusting for residence, maternal education, and wealth.ResultsThe final analysis included 89 902 samples. Ownership of HBR was associated with significantly higher odds of completing the continuum of quality MCH care compared with not owning HBR. However, no significant differences were observed between owners of MCHHB and those of other HBR types. Based on analysing the subgroups of MCH service components, the MCHHB may facilitate the provision of ANC services, such as urine and blood tests, more effectively than other HBR types.ConclusionsOwning HBR was positively associated with greater use of quality MCH services. However, no significant differences were observed for MCHHBs, despite MCHHB ownership being significantly associated with improved uptakes of urine and blood tests. Further research is needed to explore the influence of actual HBR use, provider-related factors, and variations in HBR content and type.

Maternal and child mortality are of public health concern. Most of these deaths occur in rural communities of developing countries. Technology for maternal and child health (T4MCH) is an intervention introduced to increase Maternal and Child Health (MCH) services utilization and continuum of care in some health facilities across Ghana. The objective of this study is to assess the impact of T4MCH intervention on MCH services utilization and continuum of care in the Sawla-Tuna-Kalba District in the Savannah Region of Ghana. This is a quasi-experimental study with a retrospective review of records of MCH services of women who attended antenatal services in some selected health centers in the Bole (comparison district) and Sawla-Tuna-Kalba (intervention district) of the Savannah region, Ghana. A total of 469 records were reviewed, 263 in Bole and 206 in Sawla-Tuna-Kalba. A multivariable modified Poisson and logistic regression models with augmented inverse-probability weighted regression adjustment based on propensity scores were used to quantify the impact of the intervention on service utilization and continuum of care. The implementation of T4MCH intervention increased antenatal care attendance, facility delivery, postnatal care and continuum of care by 18 percentage points (ppts) [95% CI - 17.0, 52.0], 14 ppts [95% CI 6.0%, 21.0%], 27 ppts [95% CI 15.0, 26.0] and 15.0 ppts [95% CI 8.0, 23.0] respectively compared to the control districts. The study showed that T4MCH intervention improved antenatal care, skilled delivery, postnatal services utilization, and continuum of care in health facilities in the intervention district. The intervention is recommended for a scale-up in other rural areas of Northern Ghana and the West-African sub-region.

To understand the health-seeking behaviour of adolescent women in Bangladesh with respect to the use of maternal health services. Literature review of seven electronic databases: PubMed, ISI Web of Knowledge, PsycINFO, Embase, CINAHL, POPLINE and Global Health. Studies published in English between 1990 and 2013 which describe Bangladeshi adolescent women's healthcare-seeking behaviour during pregnancy, delivery and post-partum were included. Twelve studies were included in this review. 11 used quantitative methods and one used a mixed-methods approach. All studies included married adolescent women only. Women with lower educational levels are less likely to seek skilled maternal health services than those with higher levels of education. Use of maternal health services is also less common among rural married adolescent women than women in urban areas. Being part of the richest bands of wealth, having had previous experiences of childbirth and higher women's autonomy positively influence the use of skilled maternal health services among married adolescent women in Bangladesh. Antenatal care is a key predictor of the use of skilled birth attendants for delivery and post-natal care. Maternal health-related programmes should be designed targeting rural and uneducated married adolescent women in Bangladesh. More qualitative investigations are required to broaden our understanding on maternal health-seeking behaviour of both married and unmarried adolescent women.

BackgroundThe maternal and child health (MCH) handbook is promoted as a tool for strengthening continuum of care. We assessed the effect of a MCH handbook intervention package on continuum of maternal and child health care and health outcomes for mother and child.MethodsWe conducted an open-label, parallel two-arm cluster randomized controlled trial in Angola. We randomly assigned municipalities in Benguela province through block randomization to a group using a package of enhanced maternity care service (which included the MCH handbook distribution and its supplementary intervention) and another using usual care (two stand-alone home-based records). We included women who were pregnant at the beginning of the trial period and attended a public health care facility for maternity care services. Neither health care providers, study participants nor data assessors were masked, but the statistician was. The primary outcome was a measure of service utilization assessed via achievement of maternal behavior-based continuum of care at three months postpartum. We conducted an intention-to-treat analysis in women with available data.ResultsWe randomized 10 municipalities to either the intervention (five clusters) or control (five clusters) group. Of the 11 530 women approached between June 8, 2019, and September 30, 2020, 11 006 were recruited and 9039 included in the final analysis (82%; 3774 in the intervention group and 5265 in the control group). The odds for achievement of maternal behavior-based continuum of care in the intervention group was not significantly different from that in the control group (adjusted odds ratio (aOR) = 1.18, 95% confidence interval (CI) = 0.46-2.93) at three months postpartum. However, the odds of initiating antenatal care clinic use were significantly higher in the intervention group (odds ratio (OR) = 5.16, 95% CI = 2.50-10.67). No harms associated with the intervention were reported.ConclusionsDistribution of the MCH handbook and its supplementary interventions promoted initiation of antenatal care service use, but did not increase service utilization sufficiently enough for attainment of study defined maternal behavior-based continuum of care.RegistrationISRCTN20510127.

Community health workers (CHW) faced increased challenges in delivering maternal and child health services during the current COVID-19 pandemic. In addition to routine services, they were also engaged in pandemic management. In view of a dearth of evidence, the current study explores the challenges faced by CHWs while rendering maternal and child health services. A qualitative study through in-depth interviews (IDI) and focus group discussions (FGD) in six districts of Odisha was conducted from February to April 2021. Data were analyzed using MAXQDA software. Personal-level challenges, like lack of family support, stress, and fear of contracting COVID-19; facility-level challenges, like transportation problems and inadequate personal protective measures; and community-level challenges, like stigma, resistance, and lack of community support were major hindrances in provisioning routine MCH services. Prevailing myths and misconceptions concerning COVID-19 were factors behind stigma and resistance. Sharing experiences with family, practicing yoga and pranayam, engaging ambulance bikes, financial assistance to mothers, counseling people, and involving community leaders were some effective strategies to address these challenges. Development and implementation of appropriate strategy guidelines for addressing the challenges of frontline warriors will improve their work performance and achieve uninterrupted MCH services during pandemics or similar health emergencies.

Despite high rates of early childbearing, maternal mortality, and under-five mortality, little is known about factors that affect access of teenage mothers to maternal and child health (MCH) services in Niger. This paper explores potential factors associated with the utilization of MCH care services by adolescent mothers. Using the third wave of the Niger demographic and health survey (NDHS) 2006, we estimate three multivariate logistic regression models to assess individual characteristics associated with the utilization of antenatal care (ANC) and safe delivery care services among adolescent women, as well as full immunization received by children born to adolescent mothers. The analytical sample includes 934 adolescent mothers out of 1,835 respondents aged 15-19, and within this group, 493 mother-child dyads for children aged 12-59 months. Possessing any level of education was found associated with the increased use of all three selected MCH services, while urban residence and higher income were associated with the increased use of two of three MCH services studied. Higher birth order plus a birth interval more than 2 years for the most recent birth appeared associated with the lower probability of antenatal care visits and safe delivery care. This study finds that women who attended at least four ANC visits were more likely to experience safe delivery care, and the children whose mothers had safe delivery care were more likely to receive full immunization. Therefore, an effective program should be designed to promote a continuum of MCH care with special attention to adolescent women who are uneducated, poor and residing in rural areas.

BackgroundThe maternal and child health continuum of care integrates services from pre-pregnancy through childhood to enhance maternal and child outcomes. It is crucial for reducing maternal and child mortality by focusing on comprehensive health interventions. Despite its significance, comprehensive studies on the continuum remain limited. This study aimed to assess the completion of the maternal and child health continuum of care and associated factors among mothers with index children aged 12–23 months in the West Gondar Zone, Northwest Ethiopia, in 2023.MethodsA community-based cross-sectional study was conducted from May 1–30, 2023, by interviewing mothers of 12-23-month-old children in West Gondar zone. A simple random sampling method was used to select 1,019 mothers. Data were collected via KoboCollect and analyzed in Stata version 14.0. Binary logistic regression was used to examine associations between independent variables and the continuum of care. Variables with a p value < 0.2 in bi-variable analysis were included in the multivariable model. Finally, adjusted odds ratios (AOR) with 95% confidence intervals (CI) and p values < 0.05 were used to determine statistical significance. The Hosmer and Lemeshow goodness-of-fit test was computed.ResultsThe overall rate of completion of the maternal and child health continuum of care was 6.19% (95% CI: 4.69–7.68). The factors associated were having the first ANC visit before 16 weeks of pregnancy [AOR: 4.25 (CI: 2.14–8.47)], birth preparedness and complication readiness [AOR: 3.02 (CI: 1.41–6.46)], history of modern contraceptive use [AOR: 2.34 (CI: 1.16–4.73)], intended pregnancy [AOR: 3.25 (CI: 1.63–6.48)], receiving maternal services during ANC visits [AOR: 2.69 (CI: 1.07–6.80)], and the health facility being less than an hour away from home [AOR: 2.53 (CI: 1.06–6.03)].ConclusionsThe maternal and child health (MCH) continuum of care in West Gondar was low. Key factors affecting completion included birth preparedness and complication readiness, early ANC initiation, planned pregnancy, family planning use, proximity to health facilities, and maternal health services provided during ANC. Efforts should target these factors and ensure services at each stage of the continuum to stay mothers along the path of the MCH continuum of care.

BackgroundIncreased demand for healthcare services in countries experiencing high HIV disease burden and often coupled with a shortage of health workers, has necessitated task shifting from professional health workers to Lay Health Workers (LHWs) in order to improve healthcare delivery. Maternal and Child Health (MCH) services particularly benefit from task-shifting to LHWs or similar cadres. However, evidence on the roles and usefulness of LHWs in MCH service delivery in Sub-Saharan Africa (SSA) is not fully known.ObjectivesTo examine evidence of the roles and impact of lay health worker programmes focusing on Women Living with HIV (WLH) and their HIV-exposed infants (HEIs).MethodsA scoping review approach based on Arksey and O’Malley’s guiding principles was used to retrieve, review and analyse existing literature. We searched for articles published between January 2008 and July 2018 in seven (7) databases, including: MEDLINE, Embase, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews and Web of Science. The critical constructs used for the literature search were “lay health worker”, “community health worker”, “peer mentor”, “mentor mother,” “Maternal and Child health worker”, “HIV positive mothers”, “HIV exposed infants” and PMTCT.ResultsThirty-three (33) full-text articles meeting the eligibility criteria were identified and included in the final analysis. Most (n = 13, 39.4%) of the included studies were conducted in South Africa and used a cluster RCT design (n = 13, 39.4%). The most commonly performed roles of LHWs in HIV specific MCH programmes included: community engagement and sensitisation, psychosocial support, linkage to care, encouraging women to bring their infants back for HIV testing and supporting default tracing. Community awareness on Mother to Child Transmission of HIV (MTCT), proper and consistent use of condoms, clinic attendance and timely HIV testing of HEIs, as well as retention in care for infected persons, have all improved because of LHW programmes.ConclusionLHWs play significant roles in the management of WLH and their HEIs, improving MCH outcomes in the process. LHW interventions are beneficial in increasing access to PMTCT services and reducing MTCT of HIV, though their impact on improving adherence to ART remains scanty. Further research is needed to evaluate ART adherence in LHW interventions targeted at WLH. LHW programmes can be enhanced by increasing supportive supervision and remuneration of LHWs.

There is a shortage and maldistribution of medically trained health professionals to deliver cost-effective maternal and child health (MCH) services. Hence, cost-effective MCH services are not available to over half the population of Uganda and progress toward the Millennium Development Goals for MCH is slow. Optimizing the roles of less specialized health workers ("task shifting") is one strategy to address the shortage and maldistribution of more specialized health professionals. (i) Lay health workers (community health workers) may reduce morbidity and mortality in children under five and neonates; and training for traditional birth attendants may improve perinatal outcomes and appropriate referrals. (ii) Nursing assistants in facilities might increase the time available from nurses, midwives, and doctors to provide care that requires more training. (iii) Nurses and midwives to deliver cost-effective MCH interventions in areas where there is a shortage of doctors. (iv) Drug dispensers to promote and deliver cost-effective MCH interventions and improve the quality of the services they provide. The costs and cost-effectiveness of all four options are uncertain. Given the limitations of the currently available evidence, rigorous evaluation and monitoring of resource use and activities is warranted for all four options. A clear policy on optimizing health worker roles. Community mobilization and reduction of out-of-pocket costs to improve mothers' knowledge and care-seeking behaviors, continuing education, and incentives to ensure health workers are competent and motivated, and community referral and transport schemes for MCH care are needed.

BackgroundStudies have shown that mobile health technologies (mHealth) enhance the use of maternal health services. However, there is limited evidence of the impact of mHealth use by community health workers (CHWs) on the use of maternal health services in sub-Saharan Africa.ObjectiveThis mixed method systematic review will explore the impact of mHealth use by CHWs on the use of the maternal health continuum of care (antenatal care, intrapartum care, and postnatal care [PNC]), as well as barriers and facilitators of mHealth use by CHWs when supporting maternal health services.MethodsWe will include studies that report the impact of mHealth by CHWs on the use of antenatal care, facility-based births, and PNC visits in sub-Saharan Africa. We will search 6 databases (MEDLINE, CINAHL, Web of Science, Embase, Scopus, and Africa Index Medicus), with additional articles identified from Google Scholar and manual screening of references of the included studies. The included studies will not be limited by language or year of publication. After study selection, 2 independent reviewers will perform title and abstract screening, followed by full-text screening to identify the final papers to be included. Data extraction and risk-of-bias assessment will be performed using Covidence software by 2 independent reviewers. We will use a Mixed Methods Appraisal Tool to perform risk-of-bias assessments on all included studies. Finally, we will perform a narrative synthesis of the outcomes, integrating information about the effect of mHealth on maternal health use and barriers and facilitators of mHealth use. This protocol follows the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) guidelines.ResultsIn September 2022, we conducted an initial search in the eligible databases. After removing duplicates, we identified 1111 studies that were eligible for the title and abstract screening. We will finalize the full-text assessment for eligibility, data extraction, assessment of methodological quality, and narrative synthesis by June 2023.ConclusionsThis systematic review will present new and up-to-date evidence on the use of mHealth by CHWs along the pregnancy, childbirth, and PNC continuum of care. We anticipate the results will inform program implementation and policy by highlighting the potential impacts of mHealth and presenting contextual factors that should be addressed to ensure the success of the programs.Trial RegistrationPROSPERO CRD42022346364; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=346364International Registered Report Identifier (IRRID)DERR1-10.2196/44066

Background: Despite their vital contributions, community health workers (CHWs) often face a complex range of factors that diminish their work performance and engagement. This in turn, affects their ability to effectively deliver maternal and child health (MCH) services and long-term commitment. Methods: A systematic review was conducted to identify factors that influence the work performance and engagement of CHWs delivering MCH services in Asia. We searched PubMed, EMBASE and Scopus from inception until August 2023. Findings were categorized according to the socioecological model. Findings: A total of 32 studies were included. At the personal level, sociodemographic characteristics, skills, and personal motivations were most influential. Interpersonal dynamics, including family and collegial relationships, played a critical role in sustaining job commitment. Organizational factors such as training opportunities, work environment, and access to resources were also significant. At the community level, social dynamics and safety consideration were emphasized for improving work performance. Finally, at the health system level, funding mechanisms and prevailing policies were found to shape long-term commitment. Several recommendations, including digital health solutions, were proposed as promising strategies to address these multilevel challenges. Interpretation: This study illustrates that CHWs’ performance and engagement are shaped by a range of interconnected factors across multiple levels. Fundamental issues limiting CHWs from functioning at work mainly revolved around not knowing enough, not having enough and not empowered enough. To enhance their work performance and engagement, future research should focus on exploring the potential of digital health solutions to address these foundational challenges. Funding: Nil

Objective: Male involvement (MI) in maternal and child health (MCH) services such as pre-conception care, antenatal care (ANC), prevention of mother-to-child transmission (PMTCT) of HIV, skilled delivery is an integral intervention that improves MCH outcomes. Suba sub County in western Kenya has the highest prevalence of HIV in Kenya. Moreover, data is skewed on men’s knowledge and perceptions regarding their involvement in MCH services. Methods: This mixed method cross-sectional study, collected data using questionnaire among 354 male participants, and conducted 4 focus group discussions (FGDs) and 6 key informant interviews (KIIs). STATA version 11 was used for quantitative data analysis. The thematic content analysis was used to analyze qualitative data. Results: The majority of the participants (52.3%) were aged >30 years, 44.9% had primary level of education and 63.1% engaged in fishing activities. About 54.5% of the participants were not aware of the Ministry of Health’s effort to enhance men’s attendance to MCH clinics, while men’s age, various cultural taboos and provider’s attitude were perceived as influencing MI in MCH services. Overall 16.3% of the participants were involved in MCH services. Health worker provider’s attitude towards men (OR 0.5, 95% Cl 0.3 to 0.8), men’s preferred time of attending MCH clinic (OR 6.7, 95% Cl 1.1-43.5), the frequency of men accompanying spouse to MCH clinic (OR 0.1, 95% Cl 0.04-0.3), duration taken to reach MCH clinic (OR 5.6, 95% Cl 1.3-24.6), use of family planning methods (OR 0.36, 95% Cl 0.18-0.72) and awareness about the methods used to reduce HIV mother to child transmission (MTCT) (OR 35, 95% Cl 0.19-0.65) were independently associated with men’s attendance of the MCH clinics. Conclusion: Significantly there was low male involvement in MCH services (16.3% compared to the > 30% targets by Kenya PMTCT guidelines, 2012) in this high HIV prevalent region. Enhanced dissemination and awareness creation on the importance of MI in MCH services could improve male involvement Key words : Male Involvement, Maternal and Child Health Services, Knowledge, Perceptions and Correlates, Suba sub county western Kenya DOI : 10.7176/JHMN/60-15 Publication date :March 31 st 2019

The motivations and barriers experienced by community health workers (CHWs) during the delivery of maternal and child health (MCH) services are less documented in Rwanda. This study aimed to explore the barriers and facilitators of implementing MCH care as perceived by CHWs. A descriptive qualitative study was conducted, and Semi-structured interviews with flow-up probing questions were used to collect data. A number of 24 interviews were conducted with CHWs from three selected sectors of the Gicumbi district including four supervisors of CHWs from each selected health center and one at the district hospital. Three focus group discussions with CHWs from each site were also conducted. Ethical approval was obtained from Mount Kenya University and permission to collect data from the study sites was granted. NVIVO software was used for analysis, and then the content analysis was adopted to identify themes merging from the interviews and focus group discussions. The study findings revealed emerged factors that facilitate the CHWs to deliver MCH services to their communities: liking their work, trust by the community, respect from the community, the willingness to help, desire to gain knowledge, being human, and sacrifice for the wellness of the community. On another hand, the findings indicated that the work of CHW has various barriers including working many hours, lack of equipment, lack of knowledge, unsatisfactory salary, heavy workload, lack of working space, lack of facilitation for communication, family conflicts, lack of specified working time, and believes.

Maternal and child health programmes often use Community Health Workers (CHWs) to help address poor access to health care, particularly in low- and middle-income countries (LMIC). Supervision has long been recognised as a critical ingredient of successful CHW programmes, yet it is often reported as either of poor quality or absent. There is little research on CHWs' own perception of supervision and to the best of our knowledge, there are no reviews synthesising the evidence of CHWs' experiences of supervision. This review identified and synthesised qualitative research evidence about the experiences and perceptions of supervision by CHWs in programmes targeting maternal and child health (MCH) in LMIC. Electronic searches were performed in the following databases: EMBASE, Medline, PsycINFO, ASSIA, ERIC and CINAHL. This review included studies during the period from 2000 to 2021. In total, 10,505 titles were screened for inclusion, of which 177 full-text articles were retrieved and assessed. Ultimately, 19 articles were included in this review. Data extraction was based on the thematic synthesis approach: coding the text of included studies line-by-line; developing descriptive themes; and generating analytical themes. Four themes emerged: (1) frequency of supervision, (2) type of supervision, (3) supervision and motivation and (4) supportive supervision. Careful consideration needs to be taken of the model of supervision used, as primary care facility-based supervisors (usually nurses), although skilled, may not have sufficient time to supervise. Employing supervisors whose sole responsibility is to supervise CHWs may be a good strategy to alleviate these issues. Sufficient time and resources need to be allocated to supervisors and they should be expected to perform regular in-the-field supervision. Involving some aspects of community oversight should also be considered. Supervisor skills and training and the long-term retention of trained supervisors also need to be an important area of focus.

BackgroundSocial capital is a set of shared values that allows individuals or groups receive emotional, instrumental or financial resources flow. In Ethiopia, despite people commonly involved in social networks, there is a dearth of evidence exploring whether membership in these networks enhances uptake of maternal and child health (MCH) services. This study aimed to explore perspectives of women, religious leaders and community health workers (CHWs) on social capital to improve uptake of MCH services in Northwest Ethiopia.MethodsWe employed a qualitative study through in-depth interviews with key informants, and focus group discussions. A maximum variation purposive sampling technique was used to select 41 study participants (11 in-depth interviews and 4 FGDs comprising 7–8 participants). Data were transcribed verbatim and thematic analysis was employed using ATLAS.ti software.ResultsFour overarching themes and 13 sub-themes of social capital were identified as factors that improve uptake of MCH services. The identified themes were social networking, social norms, community support, and community cohesion. Most women, CHWs and religious leaders participated in social networks. These social networks enabled CHWs to create awareness on MCH services. Women, religious leaders and CHWs perceived that existing social capital improves the uptake of MCH services.ConclusionThe community has an indigenous culture of providing emotional, instrumental and social support to women through social networks. So, it would be useful to consider the social capital of family, neighborhood and community as a tool to improve utilization of MCH services. Therefore, policymakers should design people-centered health programs to engage existing social networks, and religious leaders for improving MCH services.